Psychosurgery in Europe

Spurred on by excessively optimistic publications about the benefits of lobotomy, and driven by the pressures upon the public mental health system by the psychiatric casualties of World War II, psychiatrists and neurosurgeons in the USA and Europe emphatically embraced the new treatments that were available to them. Sweden, Norway, and Denmark together performed two-and-a-half times as many lobotomies per capita as the USA (Tranøy, 1996), and after the USA (with 40,000 lobotomies) and Great Britain (with 17,000), Scandinavia was the third most active region (with 9,500) in terms of absolute numbers.

Psychosurgery in Sweden

In 1939, Gösta Rylander proposed that psychosurgery should be performed in Sweden, and its psychosurgery programme has been active for the last 60 years. It is claimed by Tranøy (1996) that without the influence of Walter Freeman lobotomy might never have been adopted. Freeman visited Copenhagen in August 1939 and lectured on lobotomy. His book Psychosurgery was published in 1942. In Denmark, there was initial resistance to the new treatment but the early reports emerging from the USA and Great Britain were simply too compelling.

The first lobotomy in Scandinavia was performed at Gaustad Mental Hospital, Oslo in 1941. The practice was led by Ørnulv Ødegård, the director of Gaustad Mental Hospital, who had studied under Adolf Meyer in the USA and he had retained many contacts there. It is estimated that 2500 patients underwent lobotomy in Norway, frequently in mental hospitals rather than neurosurgical centres as a consequence of the geography (Tranøy & Blomberg, 2005). Norway was a little unusual in that it embraced transorbital lobotomy, and its psychosurgery programme had high mortality rates with almost 30% of patients dying shortly after surgery (Tranøy, 1996). Psychosurgery was last performed in Norway in the mid 1970s and in Denmark in 1981.

The Swedish lobotomy programme performed approximately 4,500 operations between 1944 and 1966, with 28% of all operations being performed in two hospitals; Umedalen, and Sidsjön State Mental Hospital. At Umedalen, women made up approximately 63% of all cases, and 63% of all deaths, which averaged out at a mortality of 7.4% between 1947 and 1955, but peaked at 17% in 1949. Of 101 women operated on between 1947 and 1949, only 14% were eventually sent home, and only 3% were able to work (Ögren & Sandlund, 2005).

Eastern Europe

Some countries, particular in Eastern Europe, were opposed to psychosurgery and the USSR announced a ban at the World Federation for Mental Health in Vienna in 1953. Arguing that it turned “an insane person into an idiot” Russian psychiatrists concluded that “lobotomy is an anti-physiological method that makes the patient an intellectual invalid” (Laurence, 1953). Another oft-cited reason for the ban was that it was considered ‘anti-Pavlovian’ and therefore anathema in the USSR at the time.

Psychosurgery in the UK

As stated above, Great Britain was second only to the USA in the total number of psychosurgical procedures performed. The rapid adoption of leucotomy in the UK during the 1940s is shown below in Figure 1.

Figure 1 : Leucotomies performed by year 1942-1954. From data by Tooth and Newton (1961)

In the 12 years between 1942 and 1954, there were 10,365 leucotomy procedures performed in England and Wales (Tooth & Newton, 1961). This was a questionnaire survey and is likely to have missed as many as 300 procedures per year. The diagnostic breakdown is given below in Table 1. The number of leucotomies by indication, during 1948-1954 is shown below in Figure 2. Whilst the procedure appeared to be in decline for both schizophrenia and affective disorders by 1954, it was increasing for the ‘Other’ category.

Figure 2: Number of Leucotomies performed in the UK, 1948-1954. From data by Tooth and Newton (1961)

The numbers of procedures performed in the USA is difficult to estimate with accuracy, but a survey of all state hospitals reported that at least 18,600 operations had been performed by 1951 (Kramer, 1954). Assuming an equal yearly distribution and that these figures do not include procedures before Freeman and Watts (1938), this equates to 1,430 procedures per year in the USA. Elliot Valenstein estimates that approximately 40,000 ‘earlier’ procedures were carried out in the USA (Valenstein, 1973, p. 55).

These numbers should be viewed in context. Clozapine, an atypical antipsychotic drug is licensed for the treatment of refractory schizophrenia (Joint Formulary Committee, 2005). Over the fifteen years from 1990 to 2005, 41,500 patients were treated with clozapine (Annan, 2005), and the rate of adoption of this new treatment is shown in Figure 3. This suggests that ablative neurosurgery was being used in both the UK and USA within the same order of magnitude as the most effective current treatment for treatment-refractory schizophrenia today.